Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery.

BACKGROUND: Enhanced recovery protocols may reduce postoperative complications and length of hospital stay. However, the implementation of these protocols requires time and financial investment. This study evaluated the cost-effectiveness of enhanced recovery implementation. METHODS: The first 50 consecutive patients treated during implementation of an enhanced recovery programme were compared with 50 consecutive patients treated in the year before its introduction. The enhanced recovery protocol principally implemented preoperative counselling, reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, optimized fluid balance, standardized postoperative analgesia, use of a no-drain policy, as well as early nutrition and mobilization. Length of stay, readmissions and complications within 30 days were compared. A cost-minimization analysis was performed. RESULTS: Hospital stay was significantly shorter in the enhanced recovery group: median 7 (interquartile range 5-12) versus 10 (7-18) days (P = 0·003); two patients were readmitted in each group. The rate of severe complications was lower in the enhanced recovery group (12 versus 20 per cent), but there was no difference in overall morbidity. The mean saving per patient in the enhanced recovery group was €1651. CONCLUSION: Enhanced recovery is cost-effective, with savings evident even in the initial implementation period.

Cervical dysplasia and associated risk factors in a juvenile detainee population.

STUDY OBJECTIVE: Canada has licensed a human papilloma virus (HPV) vaccine for adolescent females, with the goal of decreasing the incidence of HPV infection and associated cervical cancer. This study identifies the juvenile detainee population as a high-risk group for HPV infection and therefore an important target for primary prevention. DESIGN: A retrospective chart review. SETTING: Sundance Juvenile Detention Center, Kingston, Ontario, Canada. PARTICIPANTS: Female detainees admitted between 2003 and 2006. MAIN OUTCOME MEASURES: Papanicolaou (Pap) test results, sexually transmitted infection (STI) rates, and associated risk factors were collected from 119 charts. RESULTS: Of 57 recorded Pap smears, 46 (80.7%) were normal, 5 (8.8%) were reported as atypical squamous cells of unknown significance, and 6 (10.5%) were reported as low-grade squamous intraepithelial lesion. Of the women tested, 4% were positive for gonorrhea, 10% for chlamydia, 32% for bacterial vaginosis, and 5% for trichomonas; none were positive for syphilis. Of the girls, (91) (77%) had negative HIV and hepatitis B tests, two girls were hepatitis-C-positive, three had clinical evidence of genital herpes, and one showed evidence of pelvic inflammatory disease. There were 75 (63%) girls who reported sexual activity; 87% of them used contraception or protection of some kind, albeit inconsistently. Of these young females, 12 (10%) had engaged in prostitution and 13 (11%) had allegedly been raped or sexually assaulted. CONCLUSIONS: Female juvenile detainees in Kingston, Ontario, have higher rates of STIs, associated risk factors, and abnormal Pap tests than the general female adolescent population. This new information confirms that this population is at risk for HPV infection and subsequent cervical cancer.

Multiple squamous hyperplastic-fibrous inflammatory polyps of the oesophagus: a new feature of eosinophilic oesophagitis?

This report describes the unusual case of a 12-year-old boy with multiple polyps in the oesophagus and concurrent eosinophilic oesophagitis (EoE). Polyps were of a fibrous-inflammatory composition featuring eosinophils, mast cells, hyperplastic epithelium and fibrosis, which are all features described with EoE. EoE is an increasingly recognised clinicopathological disorder characterised by large numbers of eosinophils infiltrating the oesophageal mucosa. Polyps in the oesophagus are rare, have not previously been associated with EoE, and may represent a new feature of the disease.

The effects of exposure at constant (1 h) or exponentially decreasing concentrations of quinupristin/dalfopristin on biofilms of Gram-positive bacteria.

Using a biofilm model, infections by Staphylococcus aureus, coagulase-negative staphylococci and enterococci were studied. The biofilms were exposed to quinupristin/dalfopristin and five comparator antibiotics: ciprofloxacin, vancomycin, teicoplanin, flucloxacillin and erythromycin. Two methods of exposure to the drugs were used: constant for 1 h, and exponentially decreasing, with the rate of dilution being matched to the half-lives of the antibiotics. The effects of antibiotic exposure were monitored by performing viable counts on the cells eluted from the biofilms. The results are presented as the inhibitory or bactericidal effect (the reduction in numbers of bacteria eluted from the biofilms) and recovery times (the time taken for the number of cells eluted from the biofilms to return to the number eluted before the drug exposure). Quinupristin/dalfopristin was the most effective of the six antibiotics studied, especially against enterococci. However, there were no significant differences in the effects, inhibitory/ bactericidal or recovery times, produced by the two methods of exposure. The two glycopeptides showed a surprising lack of activity.

The development of a small-scale biofilm model suitable for studying the effects of antibiotics on biofilms of gram-negative bacteria.

A method for the study of membrane-associated biofilm populations of Escherichia coli ATCC 8739 using modified Swinnex filter units was developed. Biofilms were established under carbon limitation in a chemically defined simple salts medium. Cells, pressure filtered on to cellulose nitrate membranes in situ, were perfused from the sterile side. Steady-state conditions were attained at which the growth rate of the sessile cells could be demonstrated to be proportional to the flow rate of medium. The antibiotic susceptibility of these biofilms was examined by including ciprofloxacin within the perfusing medium. Susceptibility of the biofilms to ciprofloxacin was found to be affected not only by its concentration, but also by the growth rate of the bacteria.

Effect of anergy on short-lived suppressor cells in patients with cirrhosis or peripheral vascular disease.

In order to determine whether or not abnormal suppressor cell function correlates with the absence of a delayed hypersensitivity reaction (DHR) in anergic patients, Con A reactivity and the short-lived suppressor cell activity of peripheral blood lymphocytes (PBL) were studied in 4 groups of patients: (1) Those with peripheral vascular disease (PVD) who reacted with a normal DHR to the intradermal injection of one or more recall antigens; (2) patients with PVD who did not respond with a DHR to any of these antigens; (3) patients with alcohol-related cirrhosis and normal DHR; and (4) cirrhotics who showed no DHR. The data for both short-lived suppressor cell activity and Con A reactivity were not significantly different between anergic patients, patients with normal DHR, and a group of normal controls. Although cirrhotic patients have been reported to show abnormalities in cellular immunity, short-lived suppressor cell activity and Con A reactivity were not significantly different between cirrhotics with normal DHR, PVD patients with normal DHR, and normal controls.

A novel method for collecting and detecting amoxycillin in urine: a tool for testing antibiotic compliance in the community.

Assessing compliance to prescribed antibiotics in community studies of respiratory tract infections is difficult. We describe a simple method for collecting and detecting amoxycillin in urine using urine dip-sticks in conjunction with a bioassay. Urine was collected at timed intervals from eight healthy volunteers following oral amoxycillin administration. Dip-sticks inoculated with urine collected 1 and 8 h after antibiotic resulted in mean zones of inhibition of 1.75 and 1.37 cm, respectively. Amoxycillin activity remained demonstrable 14 days after inoculation of dip-sticks with urine. Dip-sticks inoculated with urine from control subjects who had not taken amoxycillin did not cause inhibition.